Membership Heeren XVII

Registration form membership Heeren XVII
Name*

PrefixFirst NameMiddle NameLast Name
Phone Number*
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Date of birth*

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Date
Address room (Wageningen or surroundings)*

Street Address

Street Address Line 2

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Address (home/parents)

Street Address

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Wur-mail*
Please enter your WUR e-mail address
Private email*
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Bank account number (IBAN)*
Ex: NL12 ABNA 1234 1234 12
Signature agreement preauthorized debit (for the payment of certain activities, contribution of articles we usepreauthorized debit)*

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Date*

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Date of signature
Bachelor or Master*

BATMBE
Registration number WUR*
Signature agreement processing personal data. The privacy guidelines can be found at: heeren17.nl/vereniging/privacyverklaring*

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I would like to participate with the buddy system (with te buddy system you will be coupled to a biosystems engineering student who can guide you to get started finding you path studying in Wageningen)

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Registration form membership Heeren XVII